What is the treatment for mastoiditis?

Treatment of Mastoiditis

The treatment of mastoiditis requires a combination of intravenous antibiotics and surgical intervention, with mastoidectomy indicated for patients who do not improve after 48 hours of IV antibiotics or those with complications such as subperiosteal abscess or intracranial complications. 1

Diagnostic Approach

• High-resolution temporal bone CT scan with contrast is the first-line imaging modality to:
  • Assess bone destruction
  • Identify complications
  • Guide surgical planning 2
• MRI should be considered as a complementary study when:
  • Intracranial complications are suspected
  • Soft tissue extension needs better characterization
  • Venous sinus thrombosis is suspected 2, 1

Initial Medical Management

Antibiotic Therapy

First-line IV antibiotic options include:

• Cloxacillin/flucloxacillin IV
• Ceftriaxone IV
• Vancomycin plus piperacillin-tazobactam
• Vancomycin plus a carbapenem
• Vancomycin plus ceftriaxone and metronidazole 1

Common pathogens to cover:

• Streptococcus pneumoniae (28-51%)
• Staphylococcus aureus (16%)
• Streptococcus pyogenes (11.5%)
• Anaerobes (6.5%) 3, 4

Duration of Therapy

• Total antibiotic therapy (IV + oral) typically lasts 2-3 weeks
• Oral therapy should continue for at least 7-10 days after IV therapy completion 1
• Patient should be reassessed within 48-72 hours of starting antibiotics 1

Surgical Management

Indications for Surgery

1. Lack of response to 48 hours of IV antibiotics
2. Presence of subperiosteal abscess
3. Evidence of bone erosion/coalescence
4. Development of intracranial complications 1

Surgical Procedures

• Mastoidectomy is the most common surgical intervention (performed in up to 77% of cases) 1, 3
• Myringotomy with or without tympanostomy tube placement
• Subperiosteal abscess drainage when present 1

Special Considerations

Fungal Mastoiditis

For chronic fungal mastoiditis:

• Surgical debridement with clean margins is essential
• Antifungal therapy based on identified pathogen:
  • Voriconazole: 6 mg/kg IV twice daily for 2 doses, then 3-4 mg/kg twice daily
  • Isavuconazole: 200 mg three times daily for days 1-2, then 200 mg daily
  • Liposomal amphotericin B: 3-5 mg/kg/day for severe cases 1

Complications to Monitor

• Intracranial extension (meningitis, brain abscess)
• Venous sinus thrombosis (occurs in approximately 3.2% of cases)
• Facial nerve paralysis
• Septicemia 1, 4

Treatment Algorithm

1. Initial presentation:

   • Obtain high-resolution CT temporal bone with contrast
   • Start IV antibiotics (covering S. pneumoniae, S. aureus, and anaerobes)
   • Perform myringotomy for drainage and culture

2. After 48 hours:

   • If improving: continue IV antibiotics
   • If not improving or worsening: proceed to mastoidectomy

3. For patients with complications at presentation:

   • Immediate surgical intervention (mastoidectomy)
   • Drainage of any subperiosteal abscess
   • MRI to evaluate for intracranial complications

4. Follow-up:

   • Regular clinical assessment
   • Transition to oral antibiotics when clinically improving
   • Total treatment duration of 2-3 weeks

Pitfalls and Caveats

• Prior antibiotic treatment for acute otitis media does not reliably prevent mastoiditis (33-81% of patients diagnosed with acute mastoiditis had received antibiotics prior to admission) 1
• Surgical failures requiring more than one procedure are more frequent with anaerobic or gram-negative infections 4
• If surgery is indicated, it should include mastoidectomy, as drainage procedures alone have higher failure rates 4
• Recurrence rates of 4-8% have been reported, with S. pneumoniae infections having a higher recurrence risk 1